Inspecting in Quality in the NHS?

During the last year there has been increased discussion and debate regarding inspection of quality for within the NHS.  This was partly triggered by the Francis report (2013) and the following Government response with the introduction of ‘Chief Inspectors’ working for the Care Quality Commission (CQC).  These inspectors are now charged with leading detailed inspections within health and social care services, building new models of inspection, feedback and ratings to both assure and inform the public about the quality of care in their local providing organisations.

On the whole this was well received, with many patient organisations in particular, highlighting how this will prevent organisations from ‘hiding’ problems and forcing transparency and action, and importantly holding people to account in light of poor care.  Indeed some organisations argue that the responses still don’t go far enough and more is still needed.   The shocking variation of quality of care across and within healthcare provisions, and professional disagreements on appropriate levels of quality and ways to deliver this, indeed points to the chasm of quality improvement that is still needed, but many agree now, that more money is not always the solution.

However, is inspection and appropriate method for improving quality?  Many would argue not.  Dr Deming one of the gurus of the quality movement insisted in his 14 principles (Deming, 1984) that organisations should: ”Cease dependence on inspection” and rather build in quality. 

My understanding of Deming’s points have been developed through many site tours to a number of manufacturing facilities who have attempted to implement total quality management (TQM) practices, including many blue-chips.  For me, that ‘inspection’ is redesigned but still an essential part of their processes, but it’s now the last line of defence rather than the only line of defence and measurement statistics were used to highlight zero problems and these are seen as a sign of success and good quality rather than a failure of inspection to spot problems.  They’ve ceased dependence on inspection, rather than eliminated inspection. 

One of the things that shocked me during visits was the explicit clarity of standards that detailed expectations at each stage of a process and importantly were agreed across all members of the team – usually after working through their differences.  Processes to reaffirm or improve the standards, rather than just use them as a ‘minimum level’ were in place using team talks together with tools such as visual management, standardised work and statistical process control (SPC) to help spot defects and use those as improvement opportunities.  Systematic root causes of quality defects, made for example through design flaws, poor maintenance, lack of knowledge or inadequate equipment or training, were addressed through team working at a local level by the people who do the work, and also spread across organisations quickly and shared with teams who had similar processes to help them prevent similar defects with their own work.  ‘Inspectors’ here became quality promoters aiming to share solutions, encourage quality improvement and raise standards, rather than just point out defects, and request action.  

Solutions to quality problems included ingenious error proofing devices that automatically prevented wrong parts being used or forgotten and each worker had operating procedures that included checking steps before handing over when signalled all of which could be copied and adapted in other areas.  Indeed the idea of inspection had been moved from ‘checking all had been done as per the specification at the end of the process’, to ‘building quality into the process and into all jobs’, and in this way the ‘reliance’ on inspection had been ceased, as a gradual process whilst the reliability of the manufacturing process improved and quality was more assured without blame.

The NHS in many areas is now doing some fantastic work such as a designing in processes to ‘build in’ quality such as WHO checklists, computerised allergy alerts for prescriptions or hi-visibility jackets to prevent interruptions during ward medication rounds. However, there are still many local processes without clearly agreed and defined quality standards (for example the 4 hour wait in Accident and emergency may be a defined standard, but it is not really agreed, more imposed!) Without quality standard definitions and agreements, methods to assure repeated reliable outcomes of those processes, first time, every time across whole organisations and clinical pathways cannot really be used robustly or deliver the kind repeatable high quality services seen in other industry sectors.  Without these agreements and definitions, a healthcare system that has ceased dependence on inspection is a long way from reality and instead Chief Inspectors will continue to assure the public that there are poor quality providers in the NHS and that something is being done – rather than promoters of ever rising standards of quality of care and quality improvement. 

It would be amazing if the NHS could cease dependence on inspection however, healthcare is still a long way from being able to claim high reliability processes and repeatable high quality outcomes for its patients and for that reason both inspection and local improvement are both needed, and as indicated by Berwick (1989) it would be naïve to suggest the total abandonment of surveillance and discipline. If we want affordable high quality healthcare, we need to cease reliance on inspection, not eliminate it and use it together with quality improvement.

 

References:

Berwick, D. M. (1989) Continuous Improvement as an ideal in healthcare. NEJM, 320(21), 1424-25.

Deming, W. E. (1984) Out of the Crisis (1st MIT Press ed.). Cambridge, Mass.: MIT Press.

Francis QC, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry. London, UK: House of Commons.